She agreed the documents she received stated "soft diet" on the top, but the meals he had been receiving clearly showed he was on a normal diet.

'Very difficult case'

"As a rule we would go along with what is in the file and the information we received was that he was on a normal diet," she said.

Mr Finzi's daughter Suzanne Miotti said her father had been on a soft diet at Wepre Villa for a considerable time, with food being pureed for him.

On the day of his death, Ms Morris said Mr Finzi ate toast for breakfast with no problems.

However, when he was being helped with a sandwich later, he started to choke. Despite efforts of staff and paramedics, he was pronounced dead at the scene.

Ms Morris said procedures surrounding the transfer of patients had since been tightened.

Coroner Mr Gittins called it "a very difficult case" and, when the inquest began in August last year, said he had grave concerns about the assessment which resulted in Mr Finzi receiving appropriate food.

He asked Ms Morris to provide him with written evidence of the new procedures.

Speaking after the hearing, Mr Finzi's son Tony said: "We don't want any other family to have to go through what we have gone through."